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Somatosensory autonomic reflexes allow electroacupuncture stimulation (ES) to modulate body physiology at distant sites1–6 (for example, suppressing severe systemic inflammation6–9). Since the 1970s, an emerging organizational rule about these reflexes has been the presence of body-region specificity1–6. For example, ES at the hindlimb ST36 acupoint but not the abdominal ST25 acupoint can drive the vagal–adrenal anti-inflammatory axis in mice10,11. The neuroanatomical basis of this somatotopic organization is, however, unknown. Here we show that PROKR2Cre-marked sensory neurons, which innervate the deep hindlimb fascia (for example, the periosteum) but not abdominal fascia (for example, the peritoneum), are crucial for driving the vagal–adrenal axis. Low-intensity ES at the ST36 site in mice with ablated PROKR2Cre-marked sensory neurons failed to activate hindbrain vagal efferent neurons or to drive catecholamine release from adrenal glands. As a result, ES no longer suppressed systemic inflammation induced by bacterial endotoxins. By contrast, spinal sympathetic reflexes evoked by high-intensity ES at both ST25 and ST36 sites were unaffected. We also show that optogenetic stimulation of PROKR2Cre-marked nerve terminals through the ST36 site is sufficient to drive the vagal–adrenal axis but not sympathetic reflexes. Furthermore, the distribution patterns of PROKR2Cre nerve fibres can retrospectively predict body regions at which low-intensity ES will or will not effectively produce anti-inflammatory effects. Our studies provide a neuroanatomical basis for the selectivity and specificity of acupoints in driving specific autonomic pathways. Neuroanatomical findings demonstrate why electroactupuncture at only specific acupoints can drive the vagal–adrenal axis and treat inflammation in mice.

Altered composition of collagen and elastin in abdominal fascia has been linked with the pathogenesis of hernias. This has not been studied amongst Africans who have hernia presentations which vary significantly from Caucasian cohorts. The aim of this study was to determine, and compare, the collagen and elastin contents of the transversalis fascia and rectus sheath of inguinal hernia patients with non-hernia controls. Twenty-five patients with solitary, primary, uncomplicated inguinal hernia and twenty-five non-hernia controls were evaluated. Biopsies of the transversalis fascia and anterior rectus sheath were stained with Masson Trichrome and Verhoeff van-Gieson to isolate collagen and elastin respectively, which were quantified using the ImageJ/Fiji® image analysis software. Inguinal hernia patients were aged 19–85 years with a mean age of 45.2 years, mean body mass index (BMI) of 23.3 kg/m2 and mean duration of hernia of 42.5 months. Lateral hernias with no hernia defect or posterior wall defect [PL0] were the predominant clinical type. There were significantly lower collagen and higher elastin content in the transversalis fascia and rectus sheath of inguinal hernia patients [P

BackgroundParastomal hernia (PH) is a common long-term complication in persons with an ostomy. Although the cause of PH may be multifactorial, the surgical technique employed for the creation of a stoma may be a risk factor for the development of PH. The traditional technique of cruciate fascia incision may predispose to increased pressure zones at the ostomy exit site, thereby increasing the risk of PH. A circular excision of the abdominal fascia at the ostomy exit site enables a uniform pressure distribution, thereby reducing the risk of PH. This hypothesis was tested in this in vitro experimental simulation study.MethodsThe effect of the surgical technique for ostomy creation on the risk of PH development was investigated in this in vitro experimental simulation study. The pressure development at the stoma site was compared for the traditional cruciate incision vs. circular fascia excision.ResultsThe pressure at the ostomy site was about four-times higher in the tradition cruciate incision technique compared to the circular excision technique. This finding was independent of unilateral (e.g. peritoneal) pressure application.ConclusionThe main finding from this study suggests that the traditional cruciate incision of the abdominal fascia for the creation of an intestinal ostomy predisposes to increased pressures at the ostomy site, thus increasing the risk of PH. This effect is not seen in the experimental setting following a circular excision of the fascia. Thus, this surgical aspect may be adopted as a possible means of reducing the risk of parastomal hernia in patients undergoing ostomy surgery.

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Open abdomen indicates the abdominal fascia is unclosed to abbreviate surgery and to reduce physiological stress. However, complications and difficulties in patient care are often encountered after operation. During May 2008 to March 2013, we performed a prospective protocol-directed observation study regarding open abdomen use in trauma patients. Bogota bag is the temporary abdomen closure initially but negative pressure dressing is used later. A goal-directed ICU care is applied and primary fascial closure is the primary endpoint. There were 242 patients received laparotomy after torso trauma and 84 (34.7%) had open abdomen. Twenty patients soon died within one day and were excluded. Among the included 64 patients, there were 49 (76.6%) males and the mean Injury Severity Score was 31.7. Uncontrolled bleeding was the major indication for open abdomen (64.1%) and the average duration of open abdomen was about 4.2 ± 2.2 days. After treatment, 53(82.8%) had primary fascia closure, which is significant for patient survival (odds ratio 21.6; 95% confidence interval: 3.27–142, p = 0.0014). Factors related to failed primary fascia closure are profound shock during operation, high Sequential Organ Failure Assessment Score in ICU and inadequate urine amount at first 48 hours admission.

Pedicled transverse rectus abdominis myocutaneous (TRAM) breast reconstruction is associated with increased abdominal wall morbidity. We present a method of abdominal wall reconstruction using an adjunct technique to validated procedures of hernia repair. This study is a retrospective, single-surgeon analysis of 21 patients between 2005 and 2012. Patients had bony suture anchoring of synthetic polypropylene mesh to the anterior superior iliac spine bilaterally and the pubic symphysis after the abdominal fascia was reconstructed. Patient mean follow-up was 62 months. Of the series, five patients underwent bilateral pedicled TRAM breast reconstruction. None of the 21 patients developed abdominal wall hernias. One patient developed postoperative bulging, which was retreated successfully. Two patients developed mesh infections; none required radical removal of mesh. There were no flap failures or loss in the series. The BARS technique for abdominal wall reconstruction provides excellent reinforcement of abdominal reconstruction in conjunction with pedicled TRAM breast reconstruction. Level of Evidence: Level IV, therapeutic study.

Parastomal hernia formation is common following formation of an abdominal stoma, with the risk of subsequent incarceration, obstruction and strangulation. Current treatment options include non-operative management, stoma relocation and fascial repair with or without mesh. The purpose of this systematic review was to evaluate the effectiveness and safety of open mesh repair of a parastomal hernia and to compare open non-mesh fascial repair with mesh techniques of parastomal hernia repair. Electronic databases were searched for studies comparing the two surgical techniques in accordance with preferred reporting items for systematic reviews and meta-analyses. The primary outcome of the study was the comparison of recurrence rates of parastomal hernia for each technique. Secondary outcomes included comparison of mortality, wound infection, mesh infection and any other complication. Twenty-seven studies of parastomal hernia repair were included and divided into two subgroups for open mesh repair and non-mesh fascial repair. Non-mesh fascial repair resulted in a high recurrence rate (around 50%). Reported recurrence rates for mesh repair were substantially lower, at 7.9-14.8%, depending on the position of the mesh in relation to the abdominal fascia and the length of follow-up. Morbidity and mortality did not differ significantly between the techniques used to repair a parastomal hernia. This study shows that mesh repair of a parastomal hernia is safe and significantly reduces the rate of recurrence compared with sutured repair, which should only be used in exceptional circumstances. There is insufficient evidence to determine which mesh technique (onlay, sublay or underlay) is most successful in terms of recurrence rates and morbidity.

With the progressive use of new diagnostic techniques, the management of penetrating abdominal stab wounds is changing. Most studies have been conducted in well-equipped trauma centers in developed countries, and there is a paucity of reports from general teaching hospitals with limited resources. We reviewed the assessment of anterior abdominal stab wounds in patients presenting to our hospital hoping to establish an evidence-based algorithm for managing such patients in busy general hospitals. The medical records of all 393 patients treated at our hospital for anterior abdominal stab wounds over a 7-year period were reviewed. Information regarding age, gender, site of the stab wound, management, and complications were analyzed. Twenty-six patients with hemodynamic instability at presentation underwent urgent laparotomy (LAP); 24 (92.3 %) of those procedures were therapeutic. Local wound exploration (LWE) proved that 114 (31 %) of all hemodynamically stable patients had no abdominal fascia penetration and consequently could be discharged home from the emergency department (ED). A total of 253 patients were found to have fascial penetration, and all were admitted for repeat clinical assessments (RCA) and imaging studies. A total of 121 (48 %) of the patients underwent abdominal exploration with 102 (84 %) therapeutic LAP procedures. Hemodynamic instability and evisceration should continue to prompt urgent LAP. For stable patients, a sequence of LWE followed by focused abdominal sonography for trauma and computed tomography scanning for unclear cases primed by RCA was found to be efficient in limiting hospital admissions and reducing the rate of non-therapeutic LAP.

Purpose In this manuscript, the authors describe an animal study comparing shrinkage, inflammatory response and fibroplasia in heavyweight (HW-PP) and lightweight polypropylene (LW-PP) meshes. Methods Both meshes were fixed on abdominal fascia of 25 Wistar rats (epifascial onlay placement). They were killed at 7, 28 and 90 days to measure the prostheses. Histological analysis was performed with hematoxylin‐ eosin for cellular counting and immunohistochemistry to measure collagen types I and III. Results The authors found that the LW-PP mesh presented greater median shrinkage than HW-PP mesh at 7 (P = .036), 28 (P = .674) and 90 days (P = .038) postoperatively. There were more neutrophils on LW-PP mesh (P = .008) at 7 days, gradually diminishing in both prostheses. Lymphocytes were similar between the implants at 7 days, diminishing about 50 % on LW-PP mesh (P \ .001) at 90 days. Macrophages and giant cells diminished on LW-PP and increased on HW-PP meshes (P \ .001). Collagen I/III ratio presented a progressive, almost fivefold rise at 90 days, on both mesh types (P \ .001). The collagen I/III ratio was similar between LW-PP and HW-PP meshes at the three times studied. Conclusions It is concluded that LW-PP showed more shrinkage than HW-PP mesh at 7 and 90 days, despite the fact that HW-PP presented more lately foreign body reaction. The collagen I/III ratio was similar between the prostheses and increased during the postimplant period.

Incisional hernia is a frequent complication of abdominal surgery (incidence 2–20%). Diagnosis by physical examination is sometimes difficult, especially in small incisional hernias or in obese patients. The additional diagnostic value of standardized ultrasonography was evaluated in this prospective study. A total of 456 patients participating in a randomized trial comparing two suture materials for closure of the abdominal fascia underwent physical examination and ultrasonography at 6-month intervals. Wound complaints and treatment of incisional hernia were also noted. Statistical analysis was performed using the Chi-squared and Fisher’s exact tests (SPSS). Interest variability analysis was performed. During a median follow-up of 31 months, 103 incisional hernias were found. A total of 82 incisional hernias were found by physical examination and an additional 21 with ultrasonography. Six of these additional hernias were symptomatic and only one of the additional hernias received operative treatment. The false-negative rates for physical examination and ultrasonography were 25.3 and 24.4%, respectively. Interest variability was low, with a Kappa of 0.697 (P

Background: : We present Bogota-VAC, a newly modified temporary abdominal closure (TAC) technique for open abdomen condition after abdominal compartment syndrome (ACS). Methods: : A thin isolation bag (Bogota bag) and a vacuum assisted closure (VAC) system were combined. A matching bag was tension-free fixed on the abdominal fascia by fascia suture. A ring shaped black polyurethane foam of the VAC system was placed into the gap between Bogota bag, abdominal fascia and the wound edge. A constant negative topic pressure of 50-75 mmHg was used in the VAC system. Results: : Intra-abdominal pressure (IAP: 22 ± 2 mmHg) of four patients with ACS after severe traumatic brain injury and one patient with isolated ACS after blunt abdominal trauma decreased significantly (p = 0.01) after decompressive laparotomy and treatment with Bogota-VAC (IAP: 10 ± 2 mmHg) and remained low, measured via urinary bladder pressure. Intracranial pressure (ICP) in the four traumatic brain injury patients decreased from 42 ± 13 mmHg to 15 ± 3 mmHg after abdominal decompression. Cerebral perfusion pressure (57 ± 14 mmHg) increased to 74 ± 2 mmHg. Conclusion: : The advantage of the presented Bogota-VAC is leak tightness, wound conditioning (soft tissue/fascia), skin protection and facilitation of nursing in combination with highest volume reserve capacity (VRC), thus preventing recurrent increased intra-abdominal and intracranial pressure in the initial phase after decompression of ACS compared to other TAC techniques

A novel method for plication of the abdominal fascia in miniabdominoplasty addresses abdominal laxity and improves the waistline. The design comprises a vertical plication of the rectus fascia from xiphoid to pubis and fusiform plication of the oblique fascias with limited undermining and scars, all in the setting of a miniabdominoplasty. The procedure was performed for 10 women undergoing surgery between January and December 2004. The technique resulted in improved tension of the entire abdomen, a decreased perimeter of the waist, and improved uniformity in the contour of the anterior and lateral view, avoiding the epigastric bulking generated when infraumbilical vertical plication is used alone. There were few minor and no major complications. At the follow-up assessment 6 months to 2 years after surgery, there was no loss of the improved muscle-aponeurotic tension or abdominal contour. Triple plication of the fascia provides a good method for improving both the waistline and abdominal laxity in the setting of a miniabdominoplasty.

OBJECTIVE: At present it is unclear whether endothelial activation is systematically present in preeclampsia or restricted to specialized vascular beds. Therefore, this study aimed to investigate the presence of generalized proinflammatory endothelial activation in severe, early-onset preeclampsia in vivo. METHODS: During caesarean section, biopsies were obtained from abdominal subcutaneous fat, abdominal fascia, and myometrium from 11 severe, early-onset preeclamptic and 19 healthy pregnant women. Prior to caesarean, section plasma levels of von Willebrand Factor (vWF), sVCAM-1, and C-reactive protein (CRP) were measured by ELISA. Consecutive cryostat sections were stained immunohistochemically for CD31, E-selectin, VCAM-1, and ICAM-1. For subcutaneous fat tissue, endothelial gene expression levels of E-selectin, VCAM-1, ICAM-1, endothelin-1 (ET-1), and endothelial nitric oxide synthase (eNOS) were quantified by real-time RT-PCR, using normalization to the endothelium-specific housekeeping genes CD31 and VE-cadherin. RESULTS: Plasma levels of vWF, sVCAM-1, and CRP were elevated in the preeclampsia group compared to the control group, indicating enhanced endothelial activation and inflammatory response in the severely diseased preeclamptic women. By immunohistochemical analysis, no E-selectin and VCAM-1 expression could be detected in, and no differences in endothelial ICAM-1 staining could be observed between the preeclampsia and the control group for all tissues studied. Endothelial gene expression levels of E-selectin, VCAM-1, ICAM-1, ET-1, and eNOS were comparable between the preeclampsia and control group. CONCLUSION: Protein and gene expression analysis of E-selectin, VCAM-1, ICAM-1, ET-1, and eNOS, key mediators involved in pro-inflammatory endothelial activation, could not identify endothelial activation in severe, early-onset preeclampsia in the tissues studied. However, elevated plasma levels of markers of endothelial activation and inflammation were observed. These results may suggest that in severe, early-onset preeclampsia pro-inflammatory endothelial cell activation is not a generalized phenomenon, but is likely restricted to (possibly organ-specific) specialized vascular beds. (J Soc Gynecol Investig 2005;12: 518–528) Copyright © 2005 by the Society for Gynecologic Investigation.

Despite numerous recent technical advances in minimally invasive surgical technique, the potential exists for serious morbidity during initial laparoscopic access. Safe access depends on adhering to well-recognized principles of trocar insertion, knowledge of abdominal anatomy, and recognition of hazards imposed by previous surgery. Applying these principles, we describe a safe, rapid, and cost-effective technique for laparoscopic access using readily available instruments. This technique emphasizes identification and incision of the point at which the midline abdominal fascia is fused with the base of the umbilicus, and the importance of the application of countertraction directly at the point of insertion. This method allows penetration under direct vision with minimal controlled axial force, and without the requirement for fascial sutures or other cumbersome aspects of the traditional open technique. While previous reports describe techniques for laparoscopic access entry based on similar anatomic and surgical principles, we describe an alternative method not yet discussed in the surgical literature.

We read with great interest the article by Wicker and colleagues [1] about the ‘‘Frankfurt concept’’ on how to handle needlestick injuries. This occupational injury occurs more often than usually thought and it is unreported in a lot of case. The algorithm for initial diagnosis and treatment developed at the University Hospital Frankfurt seems to be very useful to decrease the risk of bloodborne infections. The most important aspect of the matter is the persuasion of healthcare workers who suffer a needlestick injury to report as soon as possible their exposure to blood. That will allow a prompt evaluation of risks of infection and the need of an immediate antiviral therapy. In Infobox 1, the authors report standard precautions to prevent occupational blood exposure. They suggest the use of double gloving, wherever possible, to reduce intraoperative blood exposure. We would like to remind the reader of another modality to reduce the risk of intraoperative glove perforation, percutaneous injuries, and contact between exposed skin and a patient’s blood. In 1996, we published the results of a randomized study designed to assess the frequency of hand injuries and contamination in emergency midline abdominal procedures and to determine whether the use of a round-tipped blunt needle for abdominal fascia closure could be effective in reducing the frequency of injuries and glove perforation and increasing surgeons’ safety [2]. Abdominal fascia closure after an emergency operation seems, in fact, to be at greater risk for contamination with a needlestick injury rate of 52–76 % [3, 4]: a great effort by the needleholder is required to pass the needle through muscles and fascia, the needle tip is often hidden from the direct vision of the surgeon, especially if excessive adipose tissue is present, and the surgeon may have decreased attention, being often at the end of an exhausting emergency procedure. In our experience, sharp needles were responsible for all needlestick injuries and the risk of glove perforation was sevenfold lower when blunt needles were used. From that time, we routinely use blunt needle for celiotomy closure with excellent results. In conclusions, we believe that blunt needles and double gloving, alone or together, are the most effective modalities to prevent hand needlestick injuries and contamination and that they should always be used, especially in emergency surgical procedures.

Es wird uber die Reisfestigkeit von Wunden der Abdominalfaszie bei Kaninchen nach Naht mit verschiedenen Nahtmaterialien (Catgut plain, Catgut chromiert, PGS and Polyester) berichtet. Bis zum 21. postop. Tag hangt die Festigkeit der Bauchdeckennarbe noch entscheidend vom Vorhandensein der intakten Faden ab. PGS zeichnet sich durch besondere Gewebevertraglichkeit aus, verliert aber bereits nach dem 14. postop. Tag seine gesamte Festigkeit. Da an Langsschnitten der Abdominalfaszie grose Krafte angreifen, kann es zu deren Naht nicht empfohlen werden. Es besteht unter Umstanden die Gefahr der postoperativen Wundruptur und Bildung von Narbenhernien. Der Festigkeitsverlust von Catgut plain und von Catgut chromiert tritt erst zu einem spateren Zeitpunkt ein. Catgut verursacht aber Entzundungsreaktionen in der Wundumgebung, die zum Festigkeitsverlust des Gewebes fuhren. Auch diese Nahtmaterialien konnen zum Verschlus der Abdominalfaszie nicht empfohlen werden. Polyester, ein nicht resorbierbares Nahtmaterial, garantiert ausreichende Festigkeit, ist gewebefreundlich und kann deshalb zur Naht der Abdominalfaszie verwendet werden.

PENTAZOCINE (TALwIN| is the N-dimethylallyl analogue of phenazocine. It has weak narcotic antagonistic effects as well as moderately strong analgesic properties when given either by mouth or parenterally3 During the past five years, pentazocine has undergone clinical trials and appears to provide satisfactory analgesia in a broad range of pain syndromes? -4 Originally, the dose recommended for parenteral administration was two to three times that of morphine 6 but, with more experience, it appeared that three to five times was a more realistic requirement. This higher dose level had some disadvantages. ~ Following a careful study in animals and in human volunteers, 7-1~ it appeared to us that pentazocine might be useful as a supplement to balanced anaesthesia because it was claimed that it seldom caused addiction, and both respiratory depression and psychic side effects were not prominent, n-~4 This report deals with our clinical evaluation of pentazocine as a supplement to balanced anaesthesia for major abdominal surgery in relatively poor-risk patients. MATElalALS AND METHODS Clinical management Informed consent for the study was obtained from each patient. Premedication was with atropine 0.3 mg and scopolamine 0.3 mg subcutaneously one hour before surgery. Upon arrival in the operating room, blood samples were drawn, an electrocardiogram recording taken, and an intravenous infusion of lactated Ringer's solution started. After vital signs were obtained and recorded, 30 patients were induced with repeated serial intravenous injections of 30 mg pentazocine at one- to two-minute intervals. When an alteration in vital signs (respiration, blood pressure or state of awareness) indicated drug effect, nitrous oxide-oxygen (2--3:1) by face mask was introduced until the patient was judged to be anaesthetized. Succinylcholine (100 mg) was then administered intravenously and endotracheal intubation was accomplished. The patient was then connected to a mechanical respirator set to produce a tidal volume of 10 ml/kg at a rate of 15 to 18 per minute. During maintenance, pentazocine was administered intravenously in 30 mg increments. A dilute infusion of succinylcholine (0.1 per cent) was used to maintain muscle relaxation. Whole blood or packed red cells and electrolyte infusions were administered as indicated. No dextrose solution was given. Pentazocine and succinylcholine administration were discontinued as soon as the abdominal fascia was closed.